Provider Demographics
NPI:1427160753
Name:MIRANDA, CHARLES ALAN (OD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ALAN
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2066
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:VT
Mailing Address - Zip Code:05468-2066
Mailing Address - Country:US
Mailing Address - Phone:802-527-1126
Mailing Address - Fax:802-524-7010
Practice Address - Street 1:927 ETHAN ALLEN HIGHWAY
Practice Address - Street 2:SUITE 4
Practice Address - City:GEORGIA
Practice Address - State:VT
Practice Address - Zip Code:05468-9746
Practice Address - Country:US
Practice Address - Phone:802-527-1126
Practice Address - Fax:802-524-7010
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VTVT 187152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0006609Medicaid
VT0006609Medicaid
VTVT 6609Medicare ID - Type Unspecified